critical“The provider did not operate effective quality assurance systems to oversee the service. These systems did not ensure compliance with the fundamental standards”
medication management
1 finding
critical“The medicine management was not robust enough to demonstrate that medicines were managed safely at all times. This placed people at risk of harm.”
staff training
1 finding
critical“only two out of seven staff had up-to-date training. The staff had to complete competency assessments once they had completed their training, and one staff's assessment was not completed.”
staff competency
1 finding
critical“The registered manager did not ensure all staff were competent, skilled and had up to date training in order to carry out their role”
other
1 finding
critical“The registered manager had not obtained all the information required by the Regulations to ensure the suitability of all staff employed.”
care planning
1 finding
moderate“the support plans did not contain all information specific to people's needs and how to manage any conditions they had. Staff did not have all detailed guidance”
incident learning
1 finding
moderate“Incident/accident forms were completed inconsistently and did not indicate further review by the management team.”
record keeping
1 finding
moderate“The provider did not ensure that clear and consistent records were kept for people who use the service and the service management.”
consent capacity
1 finding
minor“provider's policies did not include much information regarding the process to follow when supporting children with decisions, consent and any capacity issues.”
communication with families
1 finding
minor“the support plans did not ensure all information presented was in a format people/children would be able to receive and understand it.”
leadership
1 finding
moderate“the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.”